QUALITY: The Unintended Consequences of Never Events

Changing anything as complex as health care can lead to unintended consequences and perverse incentives, and some health care providers see the "Never Event" initiative as chock-full of them. (Here's an article from Health Leaders Media, I'll come back to it in a moment.)

The "Never Event" policy means that Medicare will stop paying for certain avoidable errors; some states and major private insurers are following suit. Patients wouldn't have to pay themselves for the extra care, but the hospital wouldn't get reimbursed for the cost. CMS, the agency that runs Medicare, has announced one set, effective this October, and has proposed a second set for 2009 which is still being evaluated and going through the rule-making process. Medicare based its decisions on work by the National Quality Forum (NQF). We'll add both lists to the bottom of this post.

If you peruse blogs and online forums of doctors and nurses, you'll find a lot of complaints about the policy. Check out this thread on WhiteCoat Rant. Or this one by a nurse who calls himself "Country Rat" who argues that "complications are the result of the patient being sick." We haven't come across anybody defending egregious actions like operating on the wrong patient or wrong body part—certainly even the biggest CMS-hater agrees that should be a "Never Event." (please don't tell us that we just haven't looked hard enough.) Some of the nervous docs and nurses may be applying the CMS rules too broadly. Not all blood sugar problems are "Never Events," for instance, although severe ones may be in some circumstances. Some of the worries are quite reasonable; nurses for instance who wonder about whether it's realistic to raise the quality bar without addressing nursing shortages. If I were taking care of 10 extremely sick patients in the middle of the night, I might be asking myself the same questions. We've seen questions raised by clinicians about the proposal to add delirium to the list, or Legionnaire's disease, which we expect will be thrashed out or clarified in the rule-making process.

Some of the reaction, however, can be troubling. It's not comforting to know that some of the people who take care of us regard these conditions as immutable facts of medical life. Some balk at classifying MRSA infections as avoidable. But antiobiotic resistant infections can be avoided, or at least made far less frequent, as the Safe Care Campaign among other groups can show us. (For more info, see the Superbug blog by my friend Maryn McKenna, who guest posted for us last week). It's disturbing, too, when health care providers contend that pressure sores (aka bed sores or decubitus ulcers) are inevitable. Dr. Joanne Lynn, one of the nation's leading geriatricians and experts on end-of-life care, just wrapped up a stint at CMS where she worked on quality issues, and pressure sores were a key task for her. They made progress (though that particular initiative was nursing homes, not hospitals) through an innovative team approach reported in the Journal of Geriatrics, the New York Times, and the American Health Quality Association.

The Never Event policy has two goals. One of course is patient safety. The other is cost. Mistakes cost billions. Preventing mistakes can cost money too but it's money well-spent and it should end up saving money overall. Or will it? That brings us back to that Hospital Leaders article and the perverse incentives. Some of the hospital executives quoted in the article said the new rules wouldn't make much difference in how they operated, except perhaps some modest increase in personnel for more careful documentation and consistent coding when patients are admitted. But Dr. Bob Wachter, chief of the division of hospital medicine and the medical service at the UCSF Medical Center, sees a whole new kind of defensive medicine, with the hospitals adding extra steps to protect themselves from Medicare payment policies. If they can show that a patient came in with a "Never Ever" condition, from home or a nursing facility, they can't be accused of letting it develop in the hospital. Hence lots of extra pushing and probing to see what's there and who to blame it on. (Some infection screening may be a good idea -- but he's talking about more extensive screening on more patients.)

"It's going to lead at best to wasteful spending and at worst to clinically inappropriate care to make sure that [the patient's] chart looks good," Wachter was quoted as saying. More tests squander resources, and aren't necessarily good for the patient. We here at New America see his point. But we also think the Never Event approach is a valid one. There may be bumps, problems, adjustments, and Medicare—as well as hospitals—may have to make some tweaks and revisions, as they do to many new programs. That doesn't mean the basic goals—protecting patients, paying for value, spending wisely—aren't worth pursuing. Who knows how many pressure ulcers won't develop, how many infections will be thwarted, how many pneumonias will be avoided. Maybe, Country Rat RN's plaint not withstanding,  being sick is complication enough without all those extra complications.

As promised, here's the list:

Year 1:

• Object inadvertently left in after surgery
• Air embolism
• Blood incompatibility
• Catheter associated urinary tract infection
• Pressure ulcer (decubitus ulcer)
• Vascular catheter associated infection
• Surgical site infection—Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
• Certain types of falls and trauma

Proposed for year 2:

• Surgical site infections following certain elective procedures (including bariatric surgery)
• Legionnaires' disease (a type of pneumonia caused by a specific bacterium)
• Extreme blood sugar derangement
• Iatrogenic pneumothorax (collapse of the lung)
• Delirium
• Ventilator-associated pneumonia
• Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot) after total knee replacement and hip replacement procedures
• Staphylococcus aureus septicemia (bloodstream infection)
• Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)